Quality Documentation Specialist, RN

WakeMed Health & Hospitals • Raleigh, NC

1d • Onsite

About The Position

Responsible for concurrent and retrospective review of medical record documentation to collect quality data elements as specified by the CMS/TJC specifications manual or registry manual. Communicates with coding, CDI, physicians and physician extenders or nurses regarding missing, incomplete, unspecific, unclear, or conflicting documentation or impending opportunities within measured time frames. Enters findings into vendor database for hospital measures. Gathers, analyzes and shares information pertinent to documentation findings and outcomes. Provides subject matter expertise and outreach regarding measure set/registry metrics for designated population. Skills in Excel, Power Point and data visualization technology, such as Tableau, are essential. Onsite presence is an expectation as determined by manager. Location presence may be required at acute clinical care facilities.
The ideal candidate is a Registered Nurse with a strong background in cardiovascular care who combines clinical expertise with a passion for data quality, outcomes measurement, and performance improvement. This individual will be responsible for abstracting, validating, and reporting data for the Left Atrial Appendage Occlusion (LAAO/Watchman) and Transcatheter Valve Therapy (TVT) registries, ensuring accurate and timely data submission that supports regulatory compliance, quality improvement initiatives, and cardiovascular program excellence. Leveraging their clinical insight and analytical mindset, the successful candidate can follow the patient journey from pre-procedure evaluation through post-procedure follow-up, translating complex clinical events into high-quality registry data that drives improved patient outcomes, supports program performance, and advances excellence in structural heart care.

Requirements

• Registered Nurse Required
• 5 Years Nursing Required
• Skills in Excel, Power Point and data visualization technology, such as Tableau, are essential.

Nice To Haves

• Strong background in cardiovascular care
• Passion for data quality, outcomes measurement, and performance improvement
• Clinical insight and analytical mindset
• Ability to follow the patient journey from pre-procedure evaluation through post-procedure follow-up
• Ability to translate complex clinical events into high-quality registry data
• Bachelor's Degree Nursing Preferred

Responsibilities

• Concurrent and retrospective review of medical record documentation to collect quality data elements.
• Communicate with coding, CDI, physicians, physician extenders, or nurses regarding documentation issues.
• Enter findings into vendor database for hospital measures.
• Gather, analyze, and share information pertinent to documentation findings and outcomes.
• Provide subject matter expertise and outreach regarding measure set/registry metrics.
• Abstracting, validating, and reporting data for the Left Atrial Appendage Occlusion (LAAO/Watchman) and Transcatheter Valve Therapy (TVT) registries.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: Associate degree